Graduate Orthodontics Clinics at Western University

The Graduate Orthodontics Clinic only accepts referrals from dentists. This form is to be completed by a dental office only.

REFERRING DENTIST
Referral Form completed by (insert name)
Title of person completing form

Title of person completing form Admin Staff Dental Assistant Dentist
Referring Dentist Name Referring Dentist Name First Last
Referring Dentist Address Referring Dentist Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code
Referring Dentist Phone Number Referring Dentist Phone Number - ### - ### ####
Referring Dentist Fax (optional) Referring Dentist Fax (optional) - ### - ### ####
Referring Dentist Email (optional)
PATIENT INFORMATION
Patient Name Patient Name First Last
Gender

Gender Male Female Other
Date of Birth Date of Birth / MM / DD YYYY
Preferred Phone Number Preferred Phone Number - ### - ### ####
Email Address
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code
Parent/Guardian 1 Parent/Guardian 1 First Last
Relationship to Patient

Relationship to Patient Mother Father Guardian Other
Preferred Phone Number Preferred Phone Number - ### - ### ####
Alternate Phone Number (ie: work number) Alternate Phone Number (ie: work number) - ### - ### ####
Parent/Guardian 2 Parent/Guardian 2 First Last
Relationship to Patient

Relationship to Patient Mother Father Guardian Other
Preferred Phone Number Preferred Phone Number - ### - ### ####
Alternate Phone number (ie: work number) Alternate Phone number (ie: work number) - ### - ### ####
BRIEF OUTLINE OF THE PATIENT'S ORTHODONTIC CONDITION
Dentition

Dentition Primary Early Mixed Late Mixed Permanent
Missing Teeth

Missing Teeth Yes No

DENTAL PATTERN
DENTAL PATTERN	I	II	III	Right	Left
Occlusion Classification	Occlusion ClassificationI	Occlusion ClassificationII	Occlusion ClassificationIII	Occlusion ClassificationRight	Occlusion ClassificationLeft

Overjet (mm)
Overbite (%)
Normal Crowding Spacing

Arch Space
Arch SpaceNormal

Arch SpaceCrowding

Arch SpaceSpacing
No Anterior Posterior

Crossbite
CrossbiteNo

CrossbiteAnterior

CrossbitePosterior

	Normal	Crowding	Spacing
Arch Space	Arch SpaceNormal	Arch SpaceCrowding	Arch SpaceSpacing

	No	Anterior	Posterior
Crossbite	CrossbiteNo	CrossbiteAnterior	CrossbitePosterior


	Missing Teeth	Impacted Teeth	Supernumerary Teeth	Ectopic Teeth
Dental Anomalies (select all that apply)	Dental Anomalies (select all that apply)Missing Teeth	Dental Anomalies (select all that apply)Impacted Teeth	Dental Anomalies (select all that apply)Supernumerary Teeth	Dental Anomalies (select all that apply)Ectopic Teeth

Oral Hygiene

Oral Hygiene Poor Good Excellent
Patient Motivation

Patient Motivation Excellent Good Poor Unknown
SUMMARY:
In your opinion, is this a suitable case for any of the following

SUMMARY: In your opinion, is this a suitable case for any of the following Early Treatment Growth Modification Orthognathic Surgery Surgical exposure of impacted teeth Clear Aligners Multi-Disciplinary Treatment, i.e. Prostho
Are there radiographs?

Are there radiographs? Yes No
Upload radiographs or other documents here.
Additional comments (optional)
An acknowledgement letter will be sent to the referring dentist and the patient/parents.

PLEASE CONTACT THE CLINIC IF YOU HAVE NOT RECEIVED A LETTER AFTER 2 WEEKS

Graduate Orthodontics Clinics at Western University

Graduate Orthodontics Clinics at Western University

REFERRING DENTIST

PATIENT INFORMATION

BRIEF OUTLINE OF THE PATIENT'S ORTHODONTIC CONDITION

An acknowledgement letter will be sent to the referring dentist and the patient/parents. PLEASE CONTACT THE CLINIC IF YOU HAVE NOT RECEIVED A LETTER AFTER 2 WEEKS

An acknowledgement letter will be sent to the referring dentist and the patient/parents.

PLEASE CONTACT THE CLINIC IF YOU HAVE NOT RECEIVED A LETTER AFTER 2 WEEKS